New Health Chinese Medicine Clinic Registration
This form will be used as both a registration form for those coming into our clinic and also a contact tracing form. Details collected in this form will be stored for 28 days for the purpose of contact tracing if required.
First Name *
Surname *
Email or Contact Number *
Date you are visiting the clinic *
MM
/
DD
/
YYYY
COVID-19 Screening and Contact Tracing *
Please only tick if this applies to you. If you have any symptoms please alert staff. If you have been in contact with confirmed cases of COVID-19 or have been advised to self-isolate, we politely ask you to book telehealth and look forward to you visiting the clinic again. Thank you.
Required
Outline any COVID-19 symptoms you may have if relevant
COVID-19 symtoms include fever, sore throat, cough, shortness of breath, loss of taste/smell). If doesn't apply please skip
Thank you for taking your time filling in your details for COVID-19 screening and tracing.
On your arrival your temperature will be checked and please wear a mask, follow rules of physical distancing and adequate hand hygiene.
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy